Type A and Type B Alcoholism: Applicability Across Subpopulations and Treatment Settings.

Babor's classification of alcoholism uses multiple characteristics to assign subjects to two categories, called type A and type B. Type B alcoholism appears to be consistently more severe than type A. Research findings are reviewed that support the usefulness of Babor's typology for different drugs of abuse, clinical settings, gender, and race.

Babor 's classification of alcoholism uses multiple characteristics to assign subjects to two categories, called type A and type B. Type B alcoholism appears to be consistently more severe than type A. Research findings are reviewed that support the usefulness of Babor's typology for different drugs of abuse, clinical settings, gender, and race.KEY WORDS: AOD dependence; disorder classification; patient assessment; disease course; racial differences; risk factors; high risk group; treatment outcome; applied research; gender differences; patienttreatment matching R esearchers have long attempted ders 1 include factors that precede the ferences. 2Both Babor's type A and to categorize alcoholics based disorder (e.g., family history, person Cloninger's type I alcoholism are char on various defining characteris ality, childhood behavior problems, acterized by a later age of alcoholism tics, or dimensions.These attempts re and age of onset of AOD problems), onset, weaker family history (i.e., fewer flect the understanding that alcoholism severity of symptoms (e.g., amount and firstdegree relatives who are alco is not a single disease process but a frequency of AOD use), and adverse holics), less severe dependence, fewer complex biopsychosocial disorder with medical and psychosocial consequences symptoms of cooccurring psychiatric many different causes, complicating of AOD use (Babor et al. 1992b).disorders, and less psychosocial im factors, courses (i.e., expression and Evidence from both treatment pairment (i.e., negative familial, social, progression of symptoms), and out (Babor et al. 1992b) and adoption (Clon legal, or occupational consequences of drinking).Conversely, Babor's type B comes.Although some alcoholism inger 1987) studies suggests that all typologies have been based on a single subjects in any sample of alcoholics and Cloninger's type II refer to a more dimension (e.g., early versus late on can be assigned to one of two types severe alcoholism, characterized by set), typologies involving multiple di that differ consistently in multiple di  al. 1988, 1992a).
Typological studies often use a com  The clinical usefulness of any typol ogy lies, in part, in its ability to help explain the different causes, courses, prognoses, and outcomes for a disorder.In addition, a typology for AOD abusers should apply to a wide range of drugs; treatment types; and demographic di mensions, such as age, gender, socio economic status, and race.Based on this premise, the following sections will examine type A and type B alcoholism.

APPLICABILITY TO DRUGS OTHER THAN ALCOHOL
Many AOD abusers use more than one drug.Therefore, an important issue for typological research is whether the di mensions for alcoholism types apply to other drugs as well.Researchers have found elevated rates of ASPD, depres sive disorders, anxiety disorders, and multiple drug abuse among alcohol, cocaine, and opiate users (Rounsaville et al. 1982(Rounsaville et al. , 1991) ) and their firstdegree relatives4 (Mirin et al. 1991).In addi tion, the symptoms used to diagnose alcohol dependence seem to apply to cocaine and opiate dependence (Kosten et al. 1987).Thus, abusers of a range of drugs often share similar risk fac tors, symptoms, and consequences of AOD use.Until recently, however, no study had examined whether these di mensions clustered into two groups similar to the type A and type B ob served in alcoholism.
Ball and colleagues (1995) assessed 399 cocaine abusers based on dimen sions (see table 2) similar to those used in Babor's alcoholism typology study (Babor et al. 1992b).Cluster analysis revealed two welldefined types anal ogous to Babor's type A and type B. Among the cocaine abusers, 33 percent were type A and 67 percent were type B. Compared with type A, the type B subjects exhibited greater evidence of risk factors preceding their disorder (e.g., childhood behavior problems and family history of AOD abuse), more severe AOD abuse, more psy chological and social problems resulting from the disorder, and more coexisting psychiatric problems (e.g., ASPD).Further analyses indicated that type B subjects also had greater histories of aggression, criminality, violence, de pression, suicide attempts, and treatment for either AOD abuse or psychiatric disorders.These subjects also exhibited greater quantity, frequency, duration, severity, and adverse effects of cocaine abuse and had an earlier age of onset for both alcohol abuse and ASPD com pared with type A subjects.These re sults were generally consistent with Babor and colleagues' alcoholism ty pology (1992b), suggesting broad ap plicability for this typological approach to AOD disorders.
Subsequent study confirmed that the distinction between type A and type B is also valid for opiate, cocaine, and marijuana abusers (Feingold et al. in press).For each drug, more subjects were assigned to the less severe type A group based on various AOD abuse and psychiatric measures administered at the initial interview and again at a 6 month followup.The only inconsistency was that age of onset and family history did not differ considerably between type A and type B, possibly because these dimensions were measured differ ently in this study than in other studies.ism.For example, Cloninger's (1987) type II is essentially limited to men.Of the four types of alcoholism proposed by Zucker (1987), one type, associated with antisocial behavior, predominantly occurs in men, whereas another type, associated with anxiety and depression, appears to be more prevalent in women. 5n Babor and colleagues' alco holism study (Babor et al. 1992b), men were equally classified as type A or type B, but women were more often classified as type A (62 per cent).Interestingly, although type A and type B men differed from each other on all dimensions, type A and type B women did not differ on meas ures related to negative mood states (i.e., use of tranquilizers or consump tion of alcohol to relieve withdrawal and psychological distress).In anoth er study, a similar relationship was found between gender and typology in cocaine abusers (Ball et al. 1995).Although more cocaine abusers were assigned to type A than to type B, this difference was greater for women (79 percent type A) than for men (61 percent type A).Type A and type B men differed from each other on all dimensions, whereas type A and type B women did not differ from each other on measures related to family history of AOD abuse, lifetime psychiatric diagnoses, and severity of medical and legal problems.Brown and colleagues (1994) also noted that more women (95.6 percent) than men (73.0 percent) were classified as type A. In contrast, a nationwide sample of alcoholics (Schuckit et al. 1995) found that proportionately more women (36 percent) than men (15 per cent) were categorized as the more severe type B. Finally, Feingold and colleagues (in press) found no gender differences among a sample of AOD abusers.The reason for these discrep ancies is unknown.

Race
The usefulness of a given typology dimension may vary among different subpopulations.For example, variation in personality traits may be a key di mension for subjects from one racial group, whereas variation in drinking patterns may be more important for a different racial group.The relatively low numbers of minority subjects in several studies of type A and type B alcoholism (Babor et al. 1992a,b;Brown et al. 1994;Litt et al. 1992) provided no opportunity for researchers to determine the applicability of a two type model or its dimensions across races.Although Schuckit and col leagues (1995) studied an ethnically diverse national sample of alcoholics, the researchers did not examine differ ences in the racial composition of types.
In a study of cocaine abusers, Ball and colleagues (1995) found that the type Atype B distinction was mean ingful for both blacks and whites and that the dimensions were consistently more different for blacks than for whites.However, blacks were more commonly categorized as type A (74 percent) than were whites (63 percent).Feingold and colleagues (in press) found the same race difference in the typology for both cocaine and opiate abusers.

Implications for Causality
The causes of AOD abuse are complex, involving the interaction of environ mental factors and genetic predisposi tion.The twotype model seems to be fairly consistent across drug of choice, gender, and race.Although women and blacks are more commonly cat egorized as type A compared with men and whites, a significant number of women and blacks exhibit the kinds of risk factors, severity, impairment, and antisocial behavior previously thought to be more related to alcohol ism among whites and men.If AOD  panic, Asian, and American Indian populations, as well as for other cul tures and countries.

APPLICABILITY TO DIFFERENT CLINICAL SITUATIONS
The fact that "types" can be created statistically does not ensure that they have practical significance.To be clinically useful, a typology should facilitate treatment placement and planning decisions for a wide range of AOD abusers.For any given disorder, one can generally assume that hospitalized pa tients (i.e., inpatients) are more severely ill than nonhospitalized patients (i.e., outpatients) and that patients in either treatment setting are more severely ill than people with the disorder who have not sought treatment (i.e., a community sample).Babor's initial typology re search (Babor et al. 1988(Babor et al. , 1992b) ) Brown and colleagues (1994) found that the ma jority of alcoholic outpatients were classified as the less severe type A (78 percent).Schuckit and colleagues (1995) found the A-B typology to be meaningful in samples of inpatient, outpatient, and community alcohol abusers, although the researchers did not determine the proportions of type A versus type B subjects in these samples.Ball and colleagues (1995) applied the A-B typology to cocaine abusers in the three settings.The inpatient cocaine abusers included approximately equal numbers of type A and type B, as pre viously found with inpatient alcoholics (Babor et al. 1992b).Subjects in the outpatient and community samples were predominantly type A (75 per cent), as previously found with outpa tient alcoholics (Brown et al. 1994).Type A and type B inpatients differed from each other on all dimensions ex cept recent and lifetime cocaine use.Type A and type B outpatients did not differ from each other on family his tory, personality type, depression, and recent and lifetime cocaine use.Type A and type B community subjects did not differ on alcohol dependence, age of onset, and lifetime psychiatric diag noses.The differences between the three samples were not accounted for solely by differences in severity of drug dependence, because both the inpatients and outpatients were more severe cocaine abusers than were sub jects who did not seek treatment.
Feingold and colleagues (in press) extended these findings in a sample of 521 abusers of opiates, cocaine, marijuana, and alcohol.The outpatient sample included general psychiatric patients as well as AOD abusers.Ap proximately 50 percent of the patients in drug treatment were categorized as type B, compared with 22 percent of the general psychiatric patients and only 5 percent of the community sub jects.The researchers consistently ob served these differences regardless of the drug used.

TREATMENT OUTCOME AND SELECTION
Babor and colleagues (1992b) found that type B alcoholics exhibited more severe AOD abuse, social problems, and psychological distress than type A alcoholics 12 months after initial assessment.Type B subjects relapsed faster and more often and needed ad ditional treatment.Similarly, Ball and colleagues (1995) found that type B cocaine abusers experienced more se vere cocaine and alcohol dependence, psychiatric disorders, and legal and family problems at the 12month fol lowup.Feingold and colleagues (in press) found that type A alcohol abusers and cocaine abusers reported less use of their drug of choice at a 6month followup than did type B subjects, but such differences did not occur among marijuana or opiate abusers.
Alcoholism typologies may be es pecially useful in treatmentmatching studies, which attempt to determine which types of treatments work best for which types of patients.Litt and colleagues (1992) randomly assigned subjects from a sample of 79 alcoholic men to either of two treatment types.Interactional group therapy emphasizes the importance of functioning in rela tionships, whereas copingskills train ing provides basic instruction in coping with both relapse and situations that in crease the risk of relapse.Type A alco holics did better in interactional group therapy than in copingskills training, whereas the reverse was true for type B subjects.These differences were main tained for 2 years following the begin ning of aftercare treatment.

WHICH ARE THE MOST IMPORTANT DIMENSIONS?
Because of its complexity, the clinical application of a multidimensional ty pological assessment may be imprac tical as it is currently defined (i.e., as multiple dimensions) and constructed (i.e., using a statistical technique).Such a typology is unlikely to gain wide clinical acceptance (e.g., for guiding treatment decisions) unless it can be implemented quickly and easily by clinicians with a range of expertise.Consequently, in several studies re viewed here, the researchers attempted to identify the more important dimen sions by statistically predicting sub jects' classification types based on the subjects' scores on a subset of these dimensions (table 3).
Ball and colleagues (1995) found that across the three subject samples (i.e., inpatient, outpatient, and com munity members), antisocial person ality and alcoholdependence severity were the most effective single dimen sions predicting cocaine abuse types.
The type A type B distinction seems to have broad clinical applicability across a range of people and situations.
Other dimensions found to be impor tant in more than one study include current and lifetime dependence sever ity, childhood behavior problems, in creased AOD usage to avoid withdrawal symptoms, and AODrelated medical problems.One of the most commonly used typology dimensions for AOD abusers-family history-did not em erge by itself as an important variable in these studies.

CONCLUSIONS
Selecting the appropriate typology di mensions for categorizing a population does not depend solely on the ability of the dimensions to cluster subjects statistically.One must first decide the purpose of the assessment.The di mensions that are best for statistically grouping subjects may differ from the dimensions that are most important for understanding the cause and course of the disorder.For example, certain ge netically influenced vulnerability fac tors (e.g., family history, childhood temperament, and behavior problems) may predispose subjects to a more severe form of AOD abuse with worse outcome (i.e., type B).This suggests that one could identify higher risk type B subjects before their problems be come severe.Subjects lacking these risk factors (i.e., type A subjects) may develop a less severe and more treat able form of AOD abuse that is more environmentally influenced.
Similarly, the dimensions that are most important for identifying high risk subjects may differ greatly from the dimensions that are most impor tant for selecting specific treatments once a disorder has become severe.A simpler typology may be useful for some purposes (e.g., patient place ment), whereas a more complex model may be better for other purposes (e.g., guiding theory and research).An important research area will be determining which dimensions are of greater significance in defining a general typological system for all AOD abusers.This may be a compli cated task, because the relative im portance of specific dimensions may vary depending on gender, culture, and the setting and purpose of assess ment.Thus, the development of an assessment measure to classify multi dimensional types for clinical and prevention purposes is also an impor tant area for research.
Given some of the variability in findings reviewed here, it seems pre mature to eliminate any typology di mensions from consideration.One could even argue that the A and B typology is too narrow, because it does not include important biological di mensions, such as neurotransmitter systems or physiological reactivity. 6 Single dimensions serve specific purposes or patient subgroups.When multiple dimensions are considered together, however, the type Atype B distinction seems to have broad clinical applicability across a range of people and situations.■ Upcoming special focus issues will examine the link between alcoholism and psychiatric disorders and drinking over the life span.Sample topics are listed below.

Alcoholism and Psychiatric Disorders
SAMUEL A. BALL, PH.D., is  an assistant professor at the Yale University School of Medicine, Department of Psychiatry, Division of Substance Abuse, New Haven, Connecticut.Support for this work was provided by National Institute on Drug Abuse grant R01 DA4029.
Type I/type A alcoholism illustrated in "Upper Class Social Gathering."Original artwork for "Temperance Tales and the Alcoholic," 1979.R e p r o d u c e d w it h p e r m is s io n f r o m t h e Journal of Studies on Alcohol.© Alcohol Research Documentation, Inc., Rutgers Uni versity Center of Alcohol Studies.

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The Challenge of Dual Diagnosis ◆ Alcoholism, Anxiety, and Depressive Disorders ◆ AlcoholUse Disorder and Severe Mental Illness ◆ Homelessness and Dual Diagnosis ◆ Alcohol's Link to Eating Disorders ◆ Comorbidity of Alcoholism and Psychiatric Disorders: Family Study Data ◆ Is Drinking a Cue for Smoking?◆ Intervention With Alcoholic Smokers ◆ Alcohol Abuse and Smoking: Dual Recoveries ◆ Treating Alcohol Problems in the Context of Other Drug Abuse Drinking Over the Life Span ◆ Risk and Benefits of Alcohol Over the Life Span ◆ Examining the Nature and Course of Alcoholism ◆ Special Section: LifeStage Issues AlcoholRelated Birth Defects Drinking and Adolescents Effect of Parental Drinking on Adolescents Drinking and Young Adults Alcohol Consumption and Marital Status Drinking and Older Individuals ◆ Alcohol Abuse and the Workplace See inside back cover for details on how to subscribe to Alcohol Health & Research World.

Table 1
Comparison of Single-Dimension With Multidimensional Typology Systems for Alcoholism
fo cused on inpatient alcoholics and found roughly equal numbers of patients clas

Table 3
Specific Typology Dimensions That Predicted Type A Versus Type B in Different Studies

Typology Dimensions Used in Various AOD 1 -Use Studies Brown et al. (1994)
1 AOD = Alcohol and other drugs.